Upper Respiratory Problems, Chapter 27

Influenza- virus, classified into types A, B, & C, but only type A & B
cause significant illness in humans.
Most deaths from FLU occur in people over 60 years of age with
underlying heart or lung disease, preventable with vaccination.
S&S- cough, fever, myalgia accompanied by headache and sore
throat. Mild symptoms= common cold. Dyspnea and diffuse
crackles are signs of pulmonary complications. Symptoms
usually subside within 7 DAYS.

Some patients, particularly older ones, experience

weakness/ lassitude that persists for weeks

Hyperactive airways and chronic cough often occur during

recovery.
Most common complication of the FLU is Pneumonia. Treatment
for pneumonia is antibiotics- usually effective if started early.
Diagnoses- viral cultures, immunofluorescences, antigen
detection tests and serology.

Appropriate samples- nasopharyngeal or throat swab, nasal

wash, or nasal aspirates

Rapid flu tests provide results within 15 min and can be

done in HCP office.

Viral cultures provide results in 3-10 days.

CARE~ Advocate for vaccination of people older than 50 yrs. of
age. Give priority to groups that can transmit influenza
(healthcare workers)

CDC recommendation! ~ Everyone 6 months of age and

older should get the Flu vaccine. Most effective when given
in the fall (mid-October) before exposure occurs.
Vaccine- 2 forms
live attenuated- nasal spray- approved for
healthy people ages 2-49
Inactivated- injection- approved for use in
people 6 months of age and older can be used
in people of increased risk.
Soreness at injection site usually only side
effect.
Contraindications- Guillain-Barre syndrome and
hypersensitivity to eggs.

Nursing Goals- relief of symptoms and prevention of secondary

infection; older adults and those with chronic illness may need
hospitalization.
Antivirals are used to treat influenza
amantadine/Symmetrel
rimantadine/Flumadine
Other antivirals: zanamivir/Relenza &
oseltamivir/Tamiflu are used to prevent and treat
the flu as well.

Zanamivir-inhaler, oseltamivir- oral capsule.

Reduce symptom duration and severity of

influenza.
Pseudoephedrine/Sudafed- large doses cause
tachycardia and palpations, esp. in patients with
cardiac disease. Overdose in those over 60 may
result in CNS depression, seizures and
hallucinations.

Sinusitis- swelling of mucosa narrows or blocks the exits of the sinuses.

Provides an area for microorganisms to grow and cause infection
Viral sinusitis follows an upper respiratory infection in which the virus
penetrates the mucous membrane and decrease ciliary transport.
Acute sinusitis usually results from upper respiratory infection, allergic
rhinitis, swimming, or dental manipulation 9 all cause inflammatory
changes and retention of secretions)
Chronic sinusitis usually lasts 3 weeks or more and is usually
associated with allergies and nasal polyps. Loss of the normal ciliated
epithelium lining in the sinus cavity.
CLINICAL MANIFESTATIONS- significant pain over the sinuses, purulent
drainage, nasal obstruction, congestion, fever, and malaise.

Patient looks and feels sick

Some patients complain of headaches that change in intensity

with position changes.

Chronic is difficult to diagnose because symptoms are

nonspecific. The patient is rarely febrile.

Many patients with asthma have sinusitis.

TREATMENT- antibiotics if infection persists more than 7 days.

Amoxicillin first-line, drug of choice. Treatment takes 10-14 days

to prevent the formation of antibiotic resistant organisms.

If symptoms do not resolve- usually a broader spectrum

antibiotic is given,
Trimethoprim/sulfamethoxazole (Bactrim) or erythromycin
Maybe used for 4-6 weeks

Instruct patients using topical decongestants to use the

medication for no longer than 3 days to prevent REBOUND
congestion due to vasodilation.
Antihistamines should be used w. caution as they dry the
mucous membranes and increase the viscosity of mucus.
Encourage patients to increase fluid intake & to use nasal
cleansing techniques
May need endoscopic surgery to relieve blockage caused by
hypertrophy or septal deviation (outpatient/local anesthesia)

NASAL POLYPS-

FOREIGN BODIES- may lodge in the upper respiratory system.

benign mucous membrane masses that form slowly in

response to repeated inflammation of the sinus or nasal mucosa. Appear as
bluish, glossy projections in the nares.
Clinical manifestations- nasal obstruction, nasal discharge, and
speech distortions
Treatment- endoscopic or laser surgery to remove. Reoccurrence is
common. Topical or systemic corticosteroids may slow polyp growth

Inorganic- like buttons or beads may cause no symptoms, and be

accidentally discovered on routine examination.
Organic like wood, cotton, peas, paper- cause inflammation and nasal
discharge, which may become purulent and foul smelling. These should
be removed through route of entry.

Sneezing with opposite nostril closed is often effective

Avoid irrigating the nose or pushing the object backward b/c

could cause aspiration and airway obstruction.

If sneezing or blowing nose does not remove the item, patient

should see HCP.

Problems of the Pharynx

Acute pharyngitis- acute inflammation of the pharyngeal walls.
(Tonsils, palate and uvula) can be cause by viral, bacterial or fungal
infection.

Viral account for 70% of cases.

Acute follicular pharyngitis (strep throat) accounts for 5-15% of

episodes in adults.

Fungal pharyngitis (candidiasis) - can develop w. prolonged use

of antibiotics or inhaled corticosteroids, OR in
immunosuppressed patients (especially HIV).

S&S- scratchy throat to severe pain on swallowing. Cultures or a

rapid strep antigen test are done to determine cause and
appropriate treatment.
White irregular patches suggest fungal (candida) infection

In diphtheria: gray-white false membrane coves he

oropharynx, nasopharynx and laryngopharynx and may
extend to the trachea.
TREATMENT- goals are infection control, symptoms relief and
prevention of secondary complications.
Strep is treated w/ antibiotics
Candida infections are treated with nystatin (Mycostatin).
Patients will swish and swallow. Treatment lasts as long
as symptoms exist.
Those taking INHALED corticosteroids are at an increased
risk for infection with Candida. Thoroughly rinsing the
mouth out w. water after using corticosteroids can prevent
this infection.
Encourage patient to increase fluid intake
Cool bland liquids do NOT irritate. CITRIC JUICES ARE
IRRITATING
Peritonsillar abscess- is a complication of acute pharyngitis or
acute tonsillitis when a bacterium invades one or both tonsils.
Tonsils can enlarge and threaten airway clearance.
Patient experience high fever, leukocytosis, hot potato
voice & chills.
IV antibiotic therapy, needle aspiration or incision and
drainage
Emergency surgery to remove tonsils may be performed /
Elective surgery may be performed after infection clears

PROBLEMS OF TRACHEA & LARYNX

Airway obstruction~ may be complete or partial..Complete is
an EMERGENCY.

Partial can follow- aspiration of food or foreign body, laryngeal

edema following extubation, laryngeal or tracheal stenosis, CNS
depression & allergic reactions.

S&S: stridor, use of accessory muscles, suprasternal &

intercostal retractions, wheezing, restlessness, tachycardia, and
cyanosis.

Interventions to reestablish a patent airway~ Heimlich

maneuver; cricothyroidotomy, endotracheal intubation, and
tracheostomy.

TESTS~ for unexplained/recurrent symptoms: chest x-ray,

pulmonary function test, and bronchoscopy.

Tracheostomy-

purpose is to maintain airway over an extended

period of time; to facilitate removal of secretion. Types of trach= Table
27-5 pg. 529

Providing trach care-

All tracheostomy tubes consist of a faceplate or flange,

which rests on the neck between the clavicles and outer
cannula. In addition, they all have an obturator which is
used when inserting the tube.
Keep obturator at bedside in case of accidental
decannulation
Some trach tubes also have an inner cannula which
can be removed for cleaning/some are disposable.
Cleaning removes mucous from inside the tube.
Must provide suctioning and care for stoma.
A trach with an inflated cuff is used if the patient is at risk
of aspiration or needs mechanical ventilation.
Cuff inflation should not exceed 20mm, if more risk for
compression of capillaries, limit blood flow, and
predispose for tracheal necrosis.
MLT- minimal leak technique- inflating the cuff with the
least amount of air to obtain seal and then withdrawing
0.1 mL of air (risk for aspiration)
When a patient can protect the airway from aspiration,
and does not require mechanical ventilation, a Cuffless
trach should be used.
Stoma matures after about 5- 7 days, try not to dislodge
in the trach.
Keep a replacement tube of EQUAL OR SMALLER
size at bedside
Do not change tapes for at least first 24 hours.
THE PHYSICIAN will perform the 1st tube change.
(Usually about a week after the tracheostomy.
IF tube becomes dislodged~ immediately attempt to replace it,
grasp the retention sutures and spread the opening (can also
use a hemostat)
If the tube cannot be replaced assess for respiratory distress
Place in semi fowlers, call for assistance
Severe dyspnea- cover stoma with a sterile dressing and
ventilate the patient with bag-mask ventilation until help
arrives.
Tables 27-6 and 27-7 pgs. 530 & 531
Pg. 532-534 NURSING CARE PLAN
Swallow dysfunction inflated cuff required for the patient who
cannot protect the airway from aspiration.
Speech with tracheostomy tube- spontaneously breathing
patients can talk when the cuff is deflated and this can be
enhanced by occluding the tube.

Patients who can swallow without risk of aspiration can

use this tube but requires suctioning for secretion
removal.
For speaking valves can be used if no risk for aspiration
Decannulation- Removal, stoma is closed with tape strips and
covered with an occlusive dressing. Dressing must be changed
if it becomes soiled or wet. Instruct the patient to splint the
stoma with fingers when they need to cough, swallow or speak.
Surgical intervention is not required; stoma will close in several
days.

HEAD & NECK CANCER -

Typically squamous cell carcinomas. Most

(90%) head and neck cancers occur in individuals 50 years or older after
prolonged use of tobacco & alcohol. Other risk factors include consumption
of a diet poor in fruits and veggies & infection by HPV.

S&S: vary with tumor location.

May be painless growth in the mouth,

non-healing ulcer, or change in the fit of dentures.

Rarely produce symptoms until the late stages: pain dysphagia,

decreased mobility of the tongue, airway obstruction, & cranial
nerve neuropathies
Diagnostic studies: laryngoscopy to visualize the larynx; CT scan or
MRI may be performed to detect local or regional spread
CARE: Stage of disease is determined and guides treatment

Stage I & II- undergo radiation therapy or surgery with the goal
of cure.

Late disease- irradiation pre/post-surgery

Brachytherapy

Surgical procedures Cordectomy-partial removal of one vocal chord

Hemilaryngectomy- removal of one vocal cord or part
of vocal cord & temp. tracheostomy
Supraglottic laryngectomy- removing structures above
the true cords (false cords and epiglottis), requires temp.
Tracheostomy because of risk for aspiration.
Both Hemilaryngectomy and Supraglottic
laryngectomy allow the voice to be
preserved, but quality is breathy and hoarse.
Total laryngectomy- entire larynx and preepiglotic
region are removed and a permanent tracheostomy is
performed.
Radical neck dissection
Modified neck dissection

Nutritional therapy- patients may not be able to taking foods

orally b/c of swelling, location of sutures, or difficulty swallowing.
Parenteral nutrition is often given the first 24-48 hours.
Anticipate swallowing problems
Learn the Supraglottic swallow table 27-8 pg. 537
Can use Thick-It to thicken liquids to enhance swallowing.
Good nutrition is important, may give antiemetic or
analgesics before meals to reduce nausea and mouth
pain.
Always eat with HOB elevated, and sit up for 30- 45
minutes after meal.
CARE PLAN_ pg. 539-540
Overall goals- patient will have patent airway, no spread
of cancer, no complications related to therapy, adequate
nutritional intake, minimal to no pain, ability to
communicate and an acceptable body image.
Voice rehab= several options are available to restore speech:
voice prosthesis, esophageal speech and electro larynx. Pg. 541
Most commonly used is the Blom-Singer prosthesis.
Electro larynx is a hand-held, battery powered device that
creates speech with the use of sound waves
Esophageal speech involves swallowing air, trapping it in
the esophagus and releasing it to make sound (belch
sounding)
Stoma care - wash around stoma daily with a moist cloth. Stoma
should be covered when coughing, during any activity that
might lead to inhalation of foreign materials. Plastic collar should
be worn when in the shower
Swimming is contraindicated
Instruct patient to wear a medic bracelet about neck
breathing